Low back pain is a condition affecting millions of humans. This syndrome causes great personal, economic and social hardship. Resultant consequences to family members, co-workers and the community are significant.
Scientific evidence indicates that the symptoms of low back pain are most commonly caused by degenerative pathology in the spinal motion segment. The spinal motion segment consists of a unit of spinal anatomy bounded by two vertebral bodies that includes the two vertebral bodies and the interposed intervertebral disc, as well as the attached ligaments, muscles and the facet joints. Degenerative pathology in the spinal motion segment is primarily related to intervertebral disc degeneration.
The fundamental causes of intervertebral disc degeneration are incompletely understood. However, scientific studies substantiate the following general conclusions about the sequential development of degenerative spinal pathology: The nucleus (the central cushion of the disc) loses nutritional support, dehydrates, and fragments. The loss in nutritional support causes nuclear tissue necrosis, the cells die. As the nuclear tissue dies, the pH in the nuclear region decreases and highly irritative chemicals form in the disc. Consequently, as the nucleus can no longer support compression loads, the annulus (the fibrous rim of the disc, surrounding the nucleus) is subjected to loading forces, in the form of compression and shear, that the annulus is poorly designed to handle.
Nociceptive nerve elements, i.e., pain generating, nerve ending afferents in the outer annulus, are stimulated by a combination of chemical and mechanical forces (leakage of irritative chemicals and compression and shear force on the annulus and spinal motion segment). These pain-detecting nerve elements propagate signals in the central and autonomic nervous system pathways, leading to the activation of central pain-modulating and pain-appreciating centers in the spinal cord and brain. The conscious portions of the brain interpret the resultant excitement of certain nerve centers in the spinal cord and brain as somatic and visceral pain.
The inventor and his team performed experimental studies directed to the tissue origin of spinal pain. The results of the inventor's observations, recorded during operations on humans undergoing spinal surgery under local anesthesia, conclusively demonstrated that the symptoms of mechanical low back pain originate when the outer portion of the degenerative intervertebral disc (and to a lesser extent, the capsule of the facet joint) is/are stimulated by mechanical forces. Kuslich, Stephen D., Ulstrom, Cynthia L.; “The Origin of Low Back Pain and Sciatica: A Microsurgical Investigation”; Orthop Clin North Am 1991 April; 22(2): 181-7.
For reasons that are not perfectly clear many, if not most, humans develop the aforementioned pathologic changes in the disc nucleus as they approach middle age. Breakdown products of the disc and facet joints stimulate sensitive nerve endings in and around the disc and facet capsule, producing low back pain, and sometimes, sciatica. This pathologic phenomenon is commonly referred to as Degenerative Disc Disease (“DDD”). Degenerative Disc Disease is the primary cause of low back pain. The DDD tissue consists of the dead and/or dying fibrocartilogenous remains of the disc nucleus and inner portions of the annulus. Various toxic chemicals—such as Substance P—have been detected in DDD discs. Other investigators have described low pH (acidity) of fluids in DDD tissue. These chemicals and fluids leak out through fissures and tears in the annulus and irritate and stimulate the nociceptive nerve endings causing back pain.
Although, effective means to prevent DDD do not exist, some relatively effective treatments for DDD do exist. A number of medical and surgical strategies are known to ameliorate symptoms. These include: pain medications that block or modulate pain afferents, or suppress central pain-recognition centers, exercises that promote tissue nutrition, flexibility and muscle strength (exercises also stimulate the release of endorphin, an endogenous morphine-like chemical), braces that restrict motion and reduce forces on tender spinal tissues, anti-inflammatory oral and injectable medications, and surgical procedures designed to remove tissues pressing on nerves, stabilize spinal motion segments and/or replace pathological tissues.
Most surgical procedures designed to relieve low back pain and sciatica involves removal of a portion of the intervertebral disc. Unfortunately, removing disc tissue leaves a void in the intervertebral space. The patient's pain following partial or complete disc removal may be more severe than the pain preceding the operation. Therefore, surgeons often perform additional operations that are intended to restabilize the spinal motion segment.
Strategies for restabilization are many and include: heating the annular region in an effort to destroy nerve endings and “strengthen” or “heal” the annulus, “fusing” the motion segment by applying bone graft on the sides of the motion segment, or within the disc space, applying rigid or semi-rigid support members on the sides of the motion segment or within the disc space, removing and replacing the entire disc with a non-flexible, articulating artificial device and removing and replacing the nucleus.
A number of artificial disc replacements have been developed. The currently available devices fall into two general categories: total disc replacements and nuclear replacements. The first category consists of total disc replacements that are made of rigid, inert substances such as metal and plastic. Examples of such devices are the Fernstrom “ball-bearing” and the LINK® and PRODISC® devices.
These types of artificial discs have five main disadvantages. First, is that the devices are relatively large and non-compressible, so they require relatively large surgical exposures, thereby increasing the chance of morbidity, including infection and hemorrhage. Second, because the devices are constructed from rigid inert metal and plastic materials, they can cause serious damage if they were to displace into positions normally occupied by local nervous or vascular tissues. Third, the device implantation requires the removal of a large portion of the annulus. Such removal greatly reduces the inherent stability of the motion segment, at least early on, before healing occurs around the implant. Fourth, these inert, rigid-component disc replacements do not reproduce natural disc mechanics. Finally, unless these devices become and remain firmly attached to the vertebral endplates, relative motion between the implant and the vertebral bone will cause erosion of the vertebral endplates, possibly leading to subsidence, instability and/or neurological or vascular damage.
A second class of disc replacement is the nuclear replacement, a form of partial disc replacement. Examples include: the Ray implant (U.S. Pat. No. 4,772,287), the Bao implant (U.S. Pat. No. 5,192,326), and the Sulzer spiral implant (U.S. Pat. No. 5,919,235).
These devices are also inert, somewhat flexible, non-biological disc replacements. They involve removal of the nucleus and replacement of the nucleus with a non-biological plastic material that may be flexible and malleable. When these devices are placed in the excavated DDD cavity, they rub against living end-plate cartilage and bone. This rubbing may cause healthy living tissue to erode. This erosion may weaken the living cartilage and bone, resulting in subsidence of the device, fragmentation of the device and perhaps, further vertebral instability. Complete displacement and dislocation of the Ray implant has been reported.
This second category of disc replacements is intended to more closely mimic natural disc mechanics. To accomplish this, some nuclear replacements utilize the water-containing properties of hydrogel. One embodiment of the Ray implant as described in U.S. Pat. Nos. 4,772,287 and 4,904,260 consists of a block of hydrogel in combination with inert jacket such as a plastic fabric casing. The Bao implant as described in U.S. Pat. No. 5,192,326 consists of hydrogel beads enclosed by a fabric shell.
Devices using large blocks of hydrogel and other inert substances have three main problems. First, there is a 10 to 50 percent extrusion rate of the prosthetic disc beyond the DDD cavity during the post-operative period. Second, because physiologic loads and movements continue after operation, this prosthetic device can erode into the intervertebral bone, increasing instability. Third, inserting the device requires a moderate sized surgical exposure.
Kotani, et al. at Hokkaido University in Japan are developing an artificial disc made of a preformed fabric matrix (Spine 2001; 26:1562-1569). The fabric matrix is intended to mimic the mechanics of a natural disc. However, this technology also has shortcomings. First, the device's insertion requires a large exposure with a loss of vertebral stabilizers, i.e., the relatively large area of annulus removed during implantation. Second, the device requires that a complex weaving procedure be undertaken during manufacture. Third, many different sizes will be required for different patients and procedures. Fourth, the device must be pre-sized to fit the cavity in the disc. Fifth, since its components contain no water-imbibing component, it cannot re-hydrate itself when local ambient pressures decrease. Thus, it cannot remain hydrated in response to diurnal rhythms and function as a natural disc would function.
Devices attempting to mimic the mechanics of a natural disc also include such devices as taught in U.S. Pat. No. 6,240,926 to Chin Gan et al. This patent uses a hybrid of cultured intervertebral disc cells and a biodegradable substrate as a nuclear replacement. The device attempts to induce intervertebral disc reformation by regenerating natural disc tissue via the introduction of cultured intervertebral disc cells. Technology such as this is in an early stage of development. Compared to the wide experience with biocompatible materials such as plastics and metals, purely biological replacements may or may not prove to be practical.
While numerous techniques and devices have been developed to stabilize a spinal motion segment in an effort to ameliorate the consequences of DDD, there is a continuing need for improvements in this field.